What Happens When You're Gone? Organ Donation in Malta.

In order to receive their United States Driver’s License, a 16-year-old must answer “Yes” or “No” to the question: Would you like to be an organ donor? If they say yes, a little red heart appears on the bottom corner of their license. This little red heart is legally binding: not even the victim's family can retract the teenager's decision post-mortem. Previous to 2016, Malta pursued the exact opposite donation model: even if a Maltese person decided to create a living will that dictated the use of their cadaver, their family had every right to deny the will’s stated donation wishes. In 2016, a new registration database and set of laws made the Maltese donation system more like America’s, and much of Europe’s. This article discusses Maltese organ donation ins-and-outs (pun intended), with reference to wider practices. How has the topic of organ donation progressed historically? Why should someone donate their organs? Why not? What is the medical process? And if one decides to donate, how do they register? Read on for all questions, answered.

In brief: giving and getting organs in Malta

In 1979 Spain became the first European nation to recognise "voluntary unpaid donation of tissues and cells". While one academic paper states that the first organ replacements occurred in Malta as early as 1950, Dr Bridget Ellul at the University of Malta states that the first organ donations started happening in Malta just after Spanish recognition, in the 1980’s. No matter when organ transplantation in Malta truly started, the first surgeries were corneal transplants. A kidney was transplanted in 1983; many more occur annually today. Then, and now, only a single heart transplant occurs in Malta during a calendar year. All other organ transplants are sent to European countries like Italy, Sicily, and the UK. Source.

Surprisingly, the actual medical systems around organ transfers were unregulated until 2012. That’s when Malta standardised the transplant process. At that time authorities were also equipped with the ability to analyse and report on the level of care at international facilities.

While other European countries have registered donor preferences on electronic national databases for years, it was in 2016 that Malta finally introduced an online national organ donor registration. Dictated by the Chapter 558 rule on Human Organs, Tissues, and Cell Donation Act, anyone aged 16 years and older is able to choose which of their organs are donated. Before then, it was possible to register in personal and public end-of-life documents that you wanted you organs donated. Alas, next-of-kin could still override your last wishes. By October 2017, 10,331 Maltese citizens had registered, which was 331 more than the government’s original target.

According to 2016 census data, 436,947 people live in Malta. One or two people (articles differ on the number) explicitly registered that they did NOT want to donate. Still: why have only ¼ of the population actually registered? And, why would someone defer donation at all? First, we must consider the methodology behind choosing one’s organic fate.

In or out

There are two types of systems for managing organ donation: opt-in or opt-out.

Opt-in systems require citizens to actively register their last wishes. If a person does not register their wishes, the family is given the choice. No family? Your organs aren’t going anywhere. Spain is an example of a country with an opt-in system. After 2016, so is Malta.

The opt-out system presumes that a person wanted their organs donated. It might also be called “presumed consent”: unless you actually objected to donation, it is presumed that you’re happy to provide your organs. Many European nations, like the UK, follow this standard. There is a great deal of debate as to which system affects educated decisions and number of donations.

Controversy Related to Donation

For even the least philosophical, organ donation can be a bit creepy. After all, it is called “harvesting,” conjuring images of Matrix-esque farms full of fingers and toes. Organ trafficking is often hyped in the media. Do not worry; Article 248C makes it a criminal offence to traffic organs in Malta. Unfortunately, many uneducated people think only of human farms and black market trades when the topic of organ donation comes to mind.

This article does not only attempt to tell you the facts. The truth is that there are many people awaiting organ donation and many less organs available. Legally and socially organ donation is considered a gift: you choose to give a chance to someone else, after yours have been exhausted. But after that basic premise, the issue becomes more complicated.

Are we informed?

The first level of controversy is based on education: does a nation’s donor rate actually reflect the informed decision of its people? One study conducted in early 2013 compared two cities in Belgium, where local laws took precedent.

One city used opt-in donation policies; the other, opt-out. In addition, the city with opt-in policies also pursued a high level of donor education. Despite widely accepted claims that greater education leads to greater donation rates, both cities in Belgium reported the same donor registration rates.

However, Spain and Malta display what many analysts believe: the trend toward organ donation registration increases when the population is educated about processes. In 1985 the Maltese government released a series of surveys about willingness to donate organs. There was a markable uptick in donation registrants in that year and the next.

Why? “Doctors found it easier to approach the families of possible donors,” states an article released by the Deputy Prime Minister. Apparently, people just need to be told that donating is an option. Then, they feel comfortable talking about it with their loved ones.

Unlike many countries, Malta does not have a transplant regulatory authority. Only one group, the Malta Transplant Support Group, works as an advocacy, lobbying, and educational entity. They advocate for opt-in policies paired with popular education, aligning with the Maltese church and current Labour government.

Culture

Remember the earlier story about American teenage drivers? That system treated all organs equally. Some countries, like Malta, allow donors to choose which organs they give. What analysts have come to find is that it’s more culturally acceptable to trade one organ than another. The Conversation discusses cultural attitudes toward eyes, for instance. In the Western world, eye contact is used to denote importance, trust, awareness, even aggression. They’re also one of the most desired subjective qualities in a mate. It’s not surprising that many Western donors choose not to offer their corneas. If they were more educated, they would know that a person’s body will not become disfigured when the cornea is removed. And, that the recipient will not have the same eye colour as the deceased. They may become more willing to donate.

Politics

Politically and socially, the organ debate has become a “hot topic.” One MaltaToday article reported that the opposing Nationalist Party wanted to create an opt-out system in Malta (the Labour party jostled opt-in legislation). In Malta, it is not clear why one Maltese party would be morally aligned with organ donation over another. In some other countries such political sentiments are aligned more obviously with social and religious beliefs.

Media

LovinMalta, a hip journalism site aimed at younger Maltese locals, wrote a strongly-worded article that created registration pressure: "You can choose to donate all your organs, or pick and choose which ones you’d rather not donate (even though you’re not really using them…)". While it may seem as if the younger generations are more likely to donate because of this perceived social impetus, reports from 1998-2008 show that people of all ages are donating organs.

Religion

One of the most highly-regarded studies of organ donation in Malta was actually conducted by the Maltese Episcopal Conference, as published on the Deputy Prime Minister’s website. The 22-page study states:

Since the first successful transplant procedures in the early fifties, the Catholic Church has explicitly supported both living organ donation and the procurement of organs from the dead. Organ donation is justified by the principles of charity and solidarity.

This is a rather liberal stance compared to that held by many Christians, who believe that donating organs is “playing God.” Death is God’s will, and no one else has a right to intervene. Interestingly, the Maltese Episcopal Conference does not support opt-out legislation in case it removes the altruistic model of giving that resonates so closely with charitable religiosity.

Doctor distrust

The Maltese Episcopal Conference paper discusses that opt-out systems may detract from the willingness of doctors and legal organisations to truly educate their populations because they support-- even desire -- organ donation. Healthy organs are in-demand, after all. In fact, the TimesofMalta explains that many people think doctors will let them die or will keep their brain-dead bodies on ventilators long after death, so that the organs can be harvested later. That’s why some countries dictate that a family must be asked before the ventilator is removed.

The Medical Process

To truly make an informed decision, it is important to understand the basic medical process of organ donations. An organ is not harvested unless it passes tests for vitality. Most organs are taken from intensive care units, not from bodies kept ventilated. Only a few organs maintain their health as the body cools (the cornea, for instance, can be harvested longer after death than the kidney). After someone is brain dead and their organs are declared healthy, their body is supplied with a fluid. The fluid is typically treated blood or a blood substitute that helps maintain freshness while a recipient is found.

In many countries an organ is donated anonymously. Malta is not one of those countries. According to the Maltese Episcopal Conference report, “It was realised that in Malta, it is impossible to maintain confidentiality as to the identity of cadaver donors. Moreover since the recipients were meeting with the donor’s relatives, ‘without any support or guidelines,’ the transplant co-ordinator is now acting as the middleman, arranging a meeting if both sides are willing to meet, through the Transplant Support Group.”

For most, the process is very emotional; it depends on the individual whether communication between donor’s family and recipient benefits the grieving process. In Malta, the option to choose communication exists.

Ready to Register?

If you’re sufficiently educated and willing to register for organ donation, you’ve got two options. Both require your e-ID. The first is to pop by your polyclinic. Using your e-ID details, fill out a registration form in-person. The second is to use this gov.mt online form, completing the same details from the comfort of your home. Beware that the forms will ask you to choose which organs you’d like to donate (in Malta, many more people choose to donate kidneys than corneas). If you choose not to register specific organs, your next-of-kin will be able to choose on your behalf. If you’ve still got questions, call +35625953342 or email organdonation.health@gov.mt.